2- and 3-Dimensional Echocardiographic Analysis of an Unusual Transient Apical Ballooning Stefano Caselli, MD, Ilaria Passaseo, MD, Paride Giannantoni, MD, Daria Santini, MD, Andrea Marcantonio, MD, and Stefano De Castro, MD, Rome, Italy We report the clinical case of a 60-year-old woman who referred to our hospital for the occurrence of typical chest pain during mild effort. At admission, the electrocardiogram showed S-T segment elevation from V 3 to V 6 , and an increase in troponin I level (11.4 ng/mL). Echocardiogram showed midapical segment akinesia with depressed ejection fraction (30%). Basal segments were hypercontractile and there was evidence of dynamic obstruction of the left ventricle with an end-systolic peak gradient of 65 mm Hg. Results of emergency coronary arteriography were normal and left ventricular angiography confirmed the midapical akinesia and hypercontractility of the basal segments. Serial 2- and 3-dimensional Doppler echocardio- graphic examinations were performed. Regression of left ventricular outflow tract obstruction was soon detected (day 3). Fifteen days after admission, 2- and 3-dimensional echocardiography showed a complete regression of both apical ballooning and wall-motion abnormalities with an improvement in overall systolic function. Segmental volumetric analysis allowed accurate assessment of regional volumes and ejection fraction, which were indicative for a progressive reverse remodeling. Regression of wall-motion abnormalities was expressed by a normalization in regional ejection fraction curves at 15 days. CASE REPORT A 60-year-old woman was referred to the emergency department of our hospital for the occurrence of atypical chest pain during mild effort. History revealed bowel surgery 3 years earlier, depressive syndrome, and no cardiovascular risk factors. No fever or infectious diseases and no stressful incidents had been reported in the previous months. At admission, the electrocardiogram (ECG) showed S-T segment elevation (Figure 1) from V 3 to V 6 , an increase in troponin I level (11.4 ng/mL), and no signs of pulmonary congestion at chest radiograph. In accordance with our intensive care department protocol, we performed a complete 2-dimensional Doppler echocardiographic examination, in- cluding 3-dimensional (3D) acquisition, for the assessment of left ven- tricular (LV) function (Table). The LV was mildly enlarged with systolic dysfunction (ejection fraction 30%). The apical and middle segments were akinetic with homogeneous wall thickness compared with the basal segments. Moreover, the latter were hypercontractile and there was evidence of systolic anterior motion of mitral subvalvular apparatus provoking dynamic obstruction of the LV with an end-systolic peak gradient of 65 mm Hg (Figure 2). No LV outflow obstruction had been reported in a previous examination. Results of emergency coronary angiography were normal and left ventriculography confirmed the apical and middle akinesia and hypercontractility of the basal segments. In view of these findings, a suggestion of a transient apical balloon- ing syndrome was raised. Treatment with -blockers, angiotensin- converting enzyme inhibitors, and aspirin was started. A sharp decrease in troponin I levels was registered in the following hours (Figure 3). Serial echocardiographic and ECG examinations were performed in the following days. Regression of LV outflow tract obstruction was soon detected (day 3) whereas a mild reduction in end-diastolic and end-systolic volumes with persistence of apical and midakinesia was then observed (day 6). A From La Sapienza, University of Rome, and M.G. Vannini Hospital (P.G.). Reprint requests: Stefano Caselli, MD, Department of Cardiovascular and Respiratory Sciences, La Sapienza, University of Rome, Viale del Policlinico 155, 00161 Rome, Italy (E-mail: stefano.caselli@uniroma1.it). 0894-7317/$34.00 Copyright 2008 by the American Society of Echocardiography. doi:10.1016/j.echo.2007.08.004 Figure 1 Electrocardiogram at admission showed S-T elevation from V 3 to V 6 . 511.e1